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Patient Referral Form

We believe in a team-focused approach to veterinary medicine. Working with referring veterinarians helps us maintain patient care standards and provide client service. While we work on dermatologic and allergy concerns for our patients, we expect that routine veterinary services (health check-ups, vaccinations, etc.) will continue to be provided through the primary veterinarian.

To refer a patient, please complete and submit the Patient Referral form, either online or by fax or e-mail. We encourage you to give us a call if you would like to briefly discuss the case before patient referral or if you have any questions or concerns.

Once the referral has been received, a vet dermatologist consultation will be scheduled with the pet owner. Following the consultation, we will communicate with the primary veterinarian’s office directly in order to provide a complete record and referral report of your patient.

OWNER INFORMATION
PATIENT INFORMATION
REFERRING VETERINARIAN INFORMATION
Desired method of referral report delivery:
STATUS OF REFERRAL
DESIRED LOCATION OF CONSULTATION
Reason for Patient Referral (Case Summary):
Diagnostics, Treatments and Response to therapy:(Please attach any diagnostic or laboratory reports)
Other Systemic/Non-Dermatologic Disease:
Special Requests or Expectations:

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